Sleep Study Address: 1087 TOWN CENTER DRIVE, ORANGE CITY, FL 32763

    (386) 917-0333 OR (386) 218-3862

    Patient Instruction Sheet – Sleep Study

    Your health care provider , has requested your attendance for an overnight Sleep Study at ADVANCED SLEEP DISORDER CENTER, located at 1087 Town Center Drive, Orange City, FL,, on at 8:30 P.M.

    **Please do not arrive before your appointment time unless previously arranged**

    Please take the time to read the following instructions carefully. Complete the enclosed forms and bring them with you along with a list of all your medications on your appointment date.

    Below are a few things that will better prepare you for your night with us:

    1. Try to avoid caffeine (coffee, tea, cola, chocolate, etc) after 5:00PM and eat dinner prior to arrival.

    2. Try not to nap on the day of your Sleep Study.

    3. Pajamas, nightgown or shorts and a T-shirt are acceptable sleeping attire. Try to avoid satin, nylon and silk fabrics as well as pajamas with elastic around the ankles. Sleeping in undergarments only is not allowed. Please be advised that members of the opposite sex may be scheduled for the same night of your study. Please dress appropriately.

    4. Personal toiletries such as toothpaste, toothbrush, etc. should be included in your overnight bag.

    5. Wash and dry your hair on the day of your sleep test prior to coming to the lab. Please leave hair free of any product. No hairpieces of any type.

    6. Do not wear make-up and limit application of moisturizer unless it is prescribed.

    7. Remove nail polish and/or artificial nails from at least two fingers.

    8. Try to get a normal night’s sleep before the test. Unless instructed otherwise by your doctor, continue to take your regular medications.

    9. If you are having a CPAP study, it is NOT necessary to bring yours. You may, however, bring your CPAP mask or nasal pillows.

    10. Testing usually ends between 5:00 AM and 5:30 AM. Please make arrangements for transportation pickup at 5:45 AM if you do not drive yourself. If your transportation arrives later than 5:45AM, there will be a $100.00-dollar charge.

    11. Due to testing requirements, no one is permitted to sleep in the bed with the patient. Family and friends are asked to make other arrangements. Should you have any special needs, please contact us prior to your Sleep Study so that we can make any necessary accommodations or arrangements.

    12. Please refrain from bringing your own pillows or linens from home. We will provide these items for you.

    13. Please note each room has a television should you wish to watch TV prior to going to sleep.

    14. lease allow 2 – 3 weeks for sleep results to be finalized.

    ADVANCED SLEEP DISORDER CENTER is staffed by highly trained healthcare professionals who are committed to making your experience as comfortable as possible. Please be advised that your technician may be of the opposite sex.

    Please note: Due to the in-depth sleep study processes and appointment limitations, all No Show appointments are subject to a $250 charge. If you are unable to keep your appointment, please call us to reschedule within 96 hours (4 days) of your arrival time in order to avoid this charge. Co-pays are also due 4 days prior to your appointment, if not paid, appointment is subject to be rescheduled. Thank you.

    1087 Town Center Drive, Orange City FL 32763
    (386) 917-0333 OR (407) 936-1800



    PATIENT QUESTIONAIRE




    LAST

    FIRST

    M.I.

    SOCIAL SECURITY NUMBER




    MALEFEMALE

    Number(s) we may use to contact and/or leave messages regarding your appointments, results and recommendations:









    Please list all medications you are currently taking, including any sedative, tranquilizers, sleeping pills and muscle relaxants, even if used infrequently.

     

     

     

     

     

     

    I hereby authorize my insurance benefits to be paid directly to the Advanced Sleep Disorder Center. I hereby authorize release of pertinent medical information to insurance carriers, medical equipment companies and / or other physicians for the continuation of health care. I understand that if my appointment is not cancelled within the guidelines of our confirmation policy, I will be responsible for a $250 cancellation fee.

     



     

    It is important for you to be as accurate as possible in answering the following questions. The purpose of this questionnaire is to get a total picture of your background and the nature of your present problem. Please complete these questions as thoroughly as you can. You may find it useful to use your bed partner’s observations or comments

     

    1. Please describe your main sleep problem, in your own words, including when and how this began and what
    treatment you have received for this in the past.

    2. How do you describe your sleep problem? Check all that apply to you

    Difficulty falling asleepWake up during the nightExcessive daytime sleepinessDifficulty awakening

    3. Has it been a continuous or an intermittent problem?

    Almost every nightFor periods of at least one weekIrregularlyOther

    4. How long has this problem bothered you?

    Longer than two yearsOne or two yearsSeveral monthsWithin the last three monthsWithin the last month

    5. Do any other members of your family have sleep problems?

    YesNo


    6. What treatment have you received for your sleep problem?

    7. How many hours of sleep do you usually get per night?

    8. At what time do you go to bed?

    WEEKDAYS
    WEEKENDS

    9. At what time do you usually wake up?

    WEEKDAYS
    WEEKENDS

    10. How long does it take for you to fall asleep?

    11. If you awakened during the night (after you first fall asleep), which part(s) of your sleep period is it?

    Soon after falling asleepMiddle of the nightEarly morning

    12. How many times do you typically wake up at night?

    13. If you wake up, in average, how long do you stay awake?

    Epworth Sleepiness Scale

    How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently;
    imagine if you were given the opportunity. Use the following scale to choose the most appropriate number for
    each situation.

     

    0 = would never doze

    1 = slight chance of dozing

    2 = moderate chance of dozing

    3 = high chance of dozing

     

    SITUATION:

    CHANCE OF DOZING

    Sitting and reading

    0123

    Sitting and talking to someone

    0123

    Lying down to rest in the afternoon when circumstances permit

    0123

    As a passenger on a care for an hour without a break

    0123

    Sitting, inactive in a public place (e.g. a theater or meeting)

    0123

    Watching TV

    0123

    Sitting quietly after lunch (without alcohol)

    0123

    In the car while stopped for a few minutes in the traffic

    0123

    Add the above values to determine your score

     

    Please rate how often you:

    Never

    Rarely

    Sometimes

    Frequently

    Constantly

    Awaken from sleep short of breath

    NeverRarelySometimesFrequentlyConstantly

    Awaken at night with heartburn, belching or cough or wheezing

    NeverRarelySometimesFrequentlyConstantly

    Snore

    NeverRarelySometimesFrequentlyConstantly

    Having breathing problems during the night

    NeverRarelySometimesFrequentlyConstantly

    Suddenly wake up gasping for breath during the night

    NeverRarelySometimesFrequentlyConstantly

    Snore loudly enough that others complain

    NeverRarelySometimesFrequentlyConstantly

    Feel unable to move (paralyzed) when waking up or falling asleep

    NeverRarelySometimesFrequentlyConstantly

    Fall asleep during the day

    NeverRarelySometimesFrequentlyConstantly

    Fall asleep involuntarily

    NeverRarelySometimesFrequentlyConstantly

    Fall asleep while driving

    NeverRarelySometimesFrequentlyConstantly

    Fall asleep when laughing or crying

    NeverRarelySometimesFrequentlyConstantly

    Remember your dreams

    NeverRarelySometimesFrequentlyConstantly

    Have trouble with work or school because of sleepiness

    NeverRarelySometimesFrequentlyConstantly

    Notice your heart pounding or beating irregularly during the night

    NeverRarelySometimesFrequentlyConstantly

    Experience vivid dreams like scenes upon waking up or falling asleep

    NeverRarelySometimesFrequentlyConstantly

    Have nightmares

    NeverRarelySometimesFrequentlyConstantly

    Experience any type of leg pain during the night

    NeverRarelySometimesFrequentlyConstantly

    Kick during the night

    NeverRarelySometimesFrequentlyConstantly

    Grind teeth during sleep

    NeverRarelySometimesFrequentlyConstantly

    Notice that part of your body jerk during the night

    NeverRarelySometimesFrequentlyConstantly

    Have morning jaw pain

    NeverRarelySometimesFrequentlyConstantly

    Experience crawling and aching feelings in your legs

    NeverRarelySometimesFrequentlyConstantly

     

    Have you ever been diagnosed with any of the following or are you being treated or followed by a physician for:

     

    Yes

    No

    If yes, please explain

    Heart Disease

    YesNo

    Heart Failure

    YesNo

    Angina

    YesNo

    Hyper Tension

    YesNo

    Previous Stroke

    YesNo

    Diabetes Mellitus

    YesNo

    Anxiety

    YesNo

    Bronchitis

    YesNo

    Bipolar Disorder

    YesNo

    Fibromyalgiar

    YesNo

    Obesity

    YesNo

    Bronchiectasis

    YesNo

    Depression

    YesNo

    Other

    YesNo

     

    Yes

    No

    If yes, please explain

    Sinusitis

    YesNo

    Poliomyelitis

    YesNo

    Cancer

    YesNo

    Arrhythmia

    YesNo

    Arthritis

    YesNo

    Asthma

    YesNo

    Emphysema

    YesNo

    Pneumonia

    YesNo

    Tuberculosis

    YesNo

    Seizures

    YesNo

    Pulmonary Fibrosis

    YesNo

    Pneumothorax

    YesNo

    Pulmonary Emboli

    YesNo

     

    Answer the question below ONLY if you have/had CPAP or BIPAP ordered.

    Are you currently using a CPAP or BiPAP machine? YesNo

    Are you currently using supplemental oxygen? YesNo

    If yes, who is your current Home Healthcare Company?

    Please indicate the current pressure of your CPAP / BiPAP:

    ABOUT US

    When it comes to breathing disorders, our physicians and staff at Pulmonary Practice Associates understand how important it is for you to choose a qualified physician who will provide the best care possible to get you back to living a healthy and comfortable life.


    1075 Town Center Dr, Orange City, FL 32763
    Phone Number: (386) 917-0333
    Fax Number: (386) 917-0335

    749 Stirling Center Place, Lake Mary, FL 32746
    Phone Number: (407) 321-8230
    Fax Number: (407) 321-0388

    8400 Red Bug Lake Road, Suite 2010, Oviedo, FL, 32765
    Phone Number: (407) 321-8230
    Fax Number: (407) 321-0388

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